Clinical Question 1: Is there evidence
to support admission versus outpatient management of a patient with
FTT?

FTT Team Recommendation:

The FTT Team STRONGLY
RECOMMEND based on low quality evidence use of a
multidisciplinary approach and consideration of outpatient
evaluation and management in a patient with FTT.

Literature supporting this
recommendation:

Historically, FTT was felt to be secondary to an organic (i.e.
underlying medical disorder) or nonorganic condition (i.e. social
dysfunction) with variation in the literature on the percentage of
patients that would ultimately be discovered to have an underlying
medical condition (Sills, 1978). Homer (1981)described patients
with a combination of organic and nonorganic etiology and Berwick
et al (1982)identified that patients from low socioeconomic
backgrounds were more likely to be admitted for nonorganic FTT.
With complicating factors for FTT patients, such as mixed etiology
and limited resources secondary to low socioeconomic status, more
focus has been paid to the role of a multidisciplinary approach to
address the multitude of needs for these patients. Utilization of a
multidisciplinary specialty clinic with health care professionals
including pediatricians, dieticians, specialized nursing, social
work, psychology and financial services have been shown to lead to
improved outcomes as well as compliance for FTT patients (Hobbs
& Hanks, 1996). In a study where patients received at home
intervention including a health visitor, dietician, pediatrician
and social worker were ultimately found to be heavier, taller and
had reported better appetites compared to controls receiving
standard therapy (Wright, Callum, Birks, & Jarvis,
1998).

Evidence against hospitalization of patients with FTT was
described by Berwick et al (1982) that identified growth during
hospitalization is a poor predictor of organic versus nonorganic
disease. Children were found to gain and lose weight irrespective
of their final diagnosis of organic versus nonorganic FTT (Berwick
et al). In addition, diagnosis of underlying disorders has not been
improved with hospitalization (Berwick et al).

At Children's Mercy Hospitals and Clinics, the Ready, Set, Grow
clinic offers this multidisciplinary team approach and should be
considered as an adjunct to hospital admission or utilization for
outpatient management after hospital discharge. Literature is not
available for outcomes of hospitalized patients using a
multidisciplinary approach. However, we recommend multidisciplinary
approach in both patients requiring hospitalization and patients
utilizing outpatient services. Not all patients with FTT will
require the use of the Ready, Set, Grow clinic, however it should
be considered for patients not responding to initial
interventions.

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time.
It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.